The correct answer is:

A transfer may be refused when the patient is currently admitted to the inpatient service of the sending hospital.

Educational Objective:

Discuss valid reasons for refusal of hospital transfers under the Emergency Medical Treatment and Active Labor Act.

Key Point:

There are 5 reasons for which a Medicare-participating hospital can refuse to accept a request for transfer under EMTALA: (1) Transfer is medically not indicated; (2) the receiving hospital does not have the capacity to accept the patient, as defined by the Centers for Medicare & Medicaid Services; (3) the sending hospital is located outside the United States; (4) the transfer is not "medically appropriate"; and (5) the patient has already been admitted to an inpatient unit at the sending hospital.

Explanation:

The EMTALA was created to prevent private hospitals from refusing to treat indigent patients with medical emergencies and transferring them in an unstable condition to public hospitals. Since then, the law has evolved to regulate multiple--but not all--transfer situations.

If a patient requires transfer to a higher level of care, then a receiving hospital with that higher level of care must generally accept the patient. There are 5 exceptions to this rule. Beware of a point of confusion: For all 5 exceptions, the receiving hospital may still accept the patient, but it becomes voluntary and lies outside of EMTALA rules rather than being mandatory and regulated by the EMTALA.

The 5 situations for which acceptance of transfer request is not mandatory are as follows:

1. Transfers may be refused if care is not medically indicated.

Examples of this include patient- or family-requested transfers or so-called "lateral" transfers requested by managed care plans or physicians (in "lateral" transfers, both hospitals have the same ability to handle the emergency condition).

2. The hospital may refuse the transfer if it lacks capacity, as defined by the Centers for Medicare & Medicaid Services.

“Capacity” is not synonymous with “occupancy limit.” Rather, it is loosely defined to include whatever is customarily performed to accommodate patients in excess of its occupancy limits (eg, if a hospital would normally call in additional staff when its own facility is overloaded, then it also needs to do so for the transfer patient).

3. The hospital has no obligation under the EMTALA to accept transfers from hospitals located outside the boundaries of the United States.

However, locations of the sending hospital out of state, or out of the receiving hospital’s designated referral area, are all unacceptable reasons to refuse transfer under the EMTALA. In addition, a hospital’s perception that the sending hospital has "skipped over" other closer hospitals is not a valid reason for refusal. Once the request is made, it becomes an EMTALA issue.

4. The hospital may refuse to accept a transfer if it is not "medically appropriate."

For example, a trauma patient may require further stabilization (eg, chest tube) before the transfer is "appropriate" or may be too unstable to skip over a closer hospital capable of stabilizing the patient’s emergency condition.

5. Under the EMTALA, the hospital may refuse to accept the transfer of an inpatient from another hospital.

Such patients may of course be transferred, but the EMTALA obligation of patient acceptance no longer applies.

Receiving hospitals may also not place conditions on their acceptance such as asking the transferring hospital to promise to take the patient back after the emergency condition has been treated, requiring additional consultations prior to transfer, or requiring the use of the receiving hospital’s ambulance or helicopter services as a condition for accepting the patient.

In addition, it is illegal under the EMTALA for a hospital to refuse or delay appropriate transfers on the basis of the patient’s insurance status or to obtain payment authorization from the patient’s managed care plan prior to transfer.

References:

Bitterman RA. Emergency Medical Treatment and Active Labor Act and medicolegal issues (chapter e11). In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:e119-e135.